What to Do When Faced With Evidence?

What to do?

Trying to follow the evidence to determine the best
intervention for your patients can be a challenge, especially when it comes to
persistent pain. It can be a challenge when you read well-done reviews that
seem to have slightly opposite conclusions.

In one breath you can look at a study like the one by Hall, et al. and think
maybe physical therapy led cognitive-behavioral (CB) interventions have some
promise. This systematic review looked at 5 RCT’s including close to 1,400
subjects between the articles. It showed that CB interventions had a small to
medium effect on reducing pain and disability, but limited effect on quality of
life when comparing to education and/or exercise interventions. The evidence
showed that when therapist received additional training in CB interventions
that target both physical and psychosocial that patients were more likely to
gain long lasting skills to help manage their symptoms on their own. Compared
to more traditional biomedical-based treatments that focus only on physical
symptoms that provide short-term benefits but with questionable sustained
effects over time.

As soon as you take that breath in and think you might be on
to something to help your patients with persistent pain, you get it taken out
of you by reading the next study. Markozannes,
et al. did an umbrella review (a review of review studies) looking into how
helpful psychological interventions are for pain reduction. They concluded that
after looking at 38 papers and performing a meta-analysis that there is a lack
of strong evidence supporting the effectiveness of psychological treatments for
pain relief.

So what do we do now? First understand and except persistent
pain is complex and it is very unlikely that one magic bullet treatment is
going to produce significant effects and be the sole key to successful outcomes
with this patient population. Then take the information from the studies and
apply to your practice with some sound clinical reasoning. Cognitive-behavioral
interventions seem to offer some small to medium effect. Not great, but some
effect. So do not get too excited but also do not throw it out. Considering
there is no intervention
showing a large effect with this patient population you realize small to medium
effect is all we have for now. Knowing that CB interventions are not the
end-all-be-all, apply other treatment interventions that have shown to have
some evidence behind them as well – aerobic exercise, strength training, sleep
hygiene, stress reduction, meditation/relaxation, diet changes, goal setting,
graded exposure, to list a few. This is what we often refer to is the PNE+
(pain neuroscience education plus other therapies). Our systematic review
revealed to us that PNE (a CB type of intervention) alone did not change pain.
It is unlikely that you will ever explain someone’s pain away. However, add it
with other interventions (PNE+) and then we start getting some positive
changes.

We need to change our focus from this intervention OR that
intervention for the person with persistent pain. It most likely will be this
intervention AND that intervention. This combination of interventions should be
found through a shared-decision making model with a patient-centered approach
to care that would most likely help a patient with persistent pain have some positive
effect on their condition.

via Dr. Kory Zimney, DPT

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